Safeguarding

Please provide the following information to help us address your safeguarding concern efficiently. Fields marked with an asterisk () are required.*

Personal Information

Contact Number

Email Address

Address:

Details of Person at Risk

Age/Date of Birth*:

Gender

Female Male

Contact Details (if known):

Incident Details

Time of Incident (if applicable):

Location of Incident*:

Concern Description

How did you become aware of this concern?*:

Involved Parties

Relationship to Person at Risk (if known)*:

Immediate Actions

Yes No

Additional Information(Are there any supporting documents or evidence you would like to provide? (Please attach any relevant files):

Any other comments or information you feel may be relevant:

Do you consent to us sharing the details of this concern with relevant parties within our organisation to resolve the issue?*:

Yes No

Have you informed any external agencies about this concern?*:

Yes No

If yes, please provide details (agency name, contact person, date reported):

Signature

Date*: